Forms & Documents

Below you will find many of the forms and documents you may need.  If you don't see a form or document you need on this page, please click here to  contact us

Forms:

 Change of Status Form: To change member information such as name, coverage election(s) or termination of coverage benefits.   General Motors employees must contact the National Benefits Center at 1-(800) 489-4646. Forms must be signed by your employer prior to submission to MercyCare.

 PHI Release Form: Use when a member would like MercyCare to provide personal health information (PHI) to a third party. Examples of this would be benefits available or claims information.

 Stay Healthy Benefit Reimbursement Form: To request reimbursement for health and wellness activities.

 ACH Form: To authorize MercyCare to take premiums due directly from a checking or savings account. This is limited to members who pay premiums directly to MercyCare.

 Grievance Appeal Form

Privacy Notice


Handbooks

 Member Handbook 2014

 Member Handbook 2013

 Member Handbook 2012

Prescription Drug Claim Forms

  Foreign Claim - Direct Member Reimbursement

  Compound Claim

  Direct Member Reimbursement

*Not all members recieve their Drug Plan benefits through MercyCare. If you are unsure, and would like to verify your prescription drug benefits, please contact your employer or MercyCare's Customer Service at 1-(800) 895-2421.

Large Group and Non Qualified Health Plans

 Certificate of Coverage-HMO

 Certificate of Coverage-EPO

 Certificate of Coverage-Plus

 Certificare of Coverage-POS

Individual Health Plans

 Certificate of Coverage - Inividual On & Off Exchange

Small Group Qualified Health Plans

  Certificate of Coverage - EPO On Exchange

   Certificate of Coverage - EPO Off Exchange

    Certificate of Coverage - HMO On Exchange

    Certificate of Coverage - HMO Off Exchange


    Certificate of Coverage - PPO On Exchange


    Certificate of Coverage - PPO Off Exchange

 


 

 


For members
Service Territory Map The Winning Choice